SCAN Baekse (HMO) Medicare Advantage Plan H5425-155 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $499.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $200.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 0 beneficiaries
SCAN Baekse (HMO) Introduction
SCAN Baekse is a Medicare Advantage HMO plan offered by SCAN Health Plan. It uses a Health Maintenance Organization (HMO) provider network and comes with prescription drug coverage. For the 2027 plan year it has a $0.00 monthly premium, $0.00 medical deductible, and $499.00 in-network maximum out-of-pocket. CMS Plan ID H5425-155 identifies this plan. The 2027 Part D prescription drug deductible is $200.00.
Plan Benefits
Cost-sharing for SCAN Baekse includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H5425-155.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | Coming soon |
| Specialist | In-network: $0 copay | Coming soon |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay | Coming soon |
| Telehealth benefit | In-network: $0 copay | Coming soon |
| Routine chiropractic | Not covered | Coming soon |
| Fitness benefits | Coming soon | Coming soon |
| Health education | In-network: $0 copay | Coming soon |
| Counseling services | Not covered | Coming soon |
| Over-the-counter drug benefits | In-network: $0 copay | Coming soon |
| Health transportation (non-emergency) | Coming soon | Coming soon |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $0 copay | Coming soon |
| Lab services | In-network: $0 copay | Coming soon |
| Outpatient x-rays | In-network: $0 copay | Coming soon |
| Diagnostic tests and procedures | In-network: $0 copay | Coming soon |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $90 copay | Coming soon |
| Worldwide emergency care | Coming soon | Coming soon |
| Urgent care | $0 copay | Coming soon |
| Inpatient hospital care | Tier 1 $0 per stay |
Coming soon |
| Skilled Nursing Facility | Tier 1 $0 per day for days 1-20 $75 per day for days 21-100 |
Coming soon |
| Ground ambulance | In-network: $100 copay | Coming soon |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $25 copay | Coming soon |
| Outpatient group therapy | In-network: $25 copay | Coming soon |
| Inpatient psychiatric hospital care | Tier 1 $0 per stay |
Coming soon |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $0 copay | Coming soon |
| Occupational therapy | In-network: $0 copay | Coming soon |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: 0%-20% coinsurance | Coming soon |
| Durable medical equipment | In-network: 0%-20% coinsurance | Coming soon |
| Prosthetics | In-network: 10% coinsurance | Coming soon |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | Coming soon |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | Coming soon |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | Coming soon |
| Dental x-rays | In-network: $0 copay | Coming soon |
| Cleaning | In-network: $0 copay | Coming soon |
| Periodontics | In-network: $0 copay | Coming soon |
| Endodontics | In-network: $0 copay | Coming soon |
| Restorative services | In-network: $0 copay | Coming soon |
| Implant services | In-network: $0 copay | Coming soon |
| Orthodontics | Not covered | Coming soon |
| Oral/Maxillofacial surgery | In-network: $0 copay | Coming soon |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | Coming soon |
| Contact lenses | In-network: $0 copay | Coming soon |
| Eyeglass frames only | In-network: $0 copay | Coming soon |
| Eyeglass lenses only | In-network: $0 copay | Coming soon |
| Eyeglasses (frames & lenses) | In-network: $0 copay | Coming soon |
| Upgrades | Not covered | Coming soon |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | Coming soon |
| Fitting/evaluation | In-network: $0 copay | Coming soon |
| Prescription hearing aids | In-network: $0 copay | Coming soon |
| OTC hearing aids | Not covered | Coming soon |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Coming soon |
| Home-based palliative care | Not covered | Coming soon |
| Personal emergency response system | Coming soon | Coming soon |
| Weight management programs | Not covered | Coming soon |
| Wigs for chemotherapy-related hair loss | Coming soon | Coming soon |
| Alternative therapies | Not covered | Coming soon |
| Massage therapy | Not covered | Coming soon |
| Home/bathroom safety devices | Not covered | Coming soon |
Certain preventive services are covered 100% by SCAN Baekse as a Part B benefit.
Prescription Drug Coverage
SCAN Baekse includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $7.28 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $200.00 annual Part D deductible. You'll pay this deductible at the pharmacy before SCAN Health Plan starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, SCAN Baekse may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | $42.00 copay | Coming soon |
| Non-Preferred Drug | 35% coinsurance | Coming soon |
| Specialty Tier | 31% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H5425)
The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (Part C) and Part D prescription drug plans each year using a 5-star system. These ratings measure plan performance in areas such as preventive care, management of chronic conditions, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for SCAN Health Plan
- Website
- SCAN Health Plan Plan Page
- Providers
- SCAN Health Plan Providers Page
- Formulary
- SCAN Health Plan Formulary Page
- Pharmacy
- SCAN Health Plan Pharmacy Page
- New Member Health Plan Help
- (888)315-7226
- New Member Health Plan TTY
- (888)722-6889
- New Member Part D Help
- (888)315-7226
- New Member Part D TTY Users
- (888)722-6889
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
SCAN Baekse (H5425-155-0) is available in the following locations:
California Counties Served
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About SCAN Baekse (HMO)
What is the monthly premium for SCAN Baekse (HMO)?
For 2027, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the MOOP for SCAN Baekse in 2027?
The annual in-network MOOP is $499.00 for 2027. After this limit is reached, covered in-network services are fully paid.
What is the CMS star rating for this plan?
For 2027, plan H5425-155 has a CMS star rating of ★0.0 out of 5 stars.
What is the current enrollment for SCAN Baekse?
Total enrollment is 0 beneficiaries based on the latest CMS data.
What is the Part D deductible for plan H5425-155?
The Part D deductible is $200.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| SCAN Health Plan (official source) | http://www.scanhealthplan.com | October 4, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Compare Original Medicare & Medicare Advantage | 25 May, 2025 |
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